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Sunday, July 29, 2012

The Difference Between Going Postal and Suffering Paranoid Schizophrenia

On Friday I tweeted (a little smug, sorry),

"Don't listen to me :). Holmes suffered from schizophrenia. Treated by a doc at U of Co, head of the department. tinyurl.com/d8p9eko."

Apparently James Holmes had been treated by the director of student mental-health services at the University of Colorado Anschutz Medical Campus.

Dr. Lynne Fenton is a researcher in schizophrenia and bipolar disorder, as well. Days after the shooting she received a package from Holmes, drawings depicting stick figures and a man with a rifle-- a mass shooting spree. Perhaps she had asked him to draw what he saw in his head.

Nobody would want to be in Dr. Fenton's position right now. It is the reason that one of my best friends got out of treating mental illness, turned academic full time, never looked back. Psychiatrists can prescribe medication, so they are the ones who see the most violent patients. Although most patients who suffer psychotic disorders are not violent, some are.

Only the strong have the stomach for this. As much as we hear about violence, we're all a little afraid that a threatening patient will turn on us, or will turn on someone else, and we will be responsible.

At lunch today the discussion turned to Holmes and someone brought out the evil card. Yours truly couldn't handle it, had to lecture about mental illness and the difference between vengeful, angry people, and those who are terrified to the core, hear demanding voices in their heads, eventually surrender to them, give in, act out.

Once I was riding my bike. Approaching a woman on the sidewalk dressed in a bright summer outfit (it wasn't summer) we locked eyes. She had an odd look and I knew, at that moment just knew, that she suffered from some psychosis, probably schizophrenia. She spat at me, missed by only a few inches, too, and I sped away. Maybe a voice in her head said,
"She's dangerous, she's on to you, she knows about you. Get her first."
A reverse empath.

Some people suffering from psychoses like schizophrenia and bi-polar disorder are so confused, their boundaries so poor, that they believe that they are not only the agents of God or The Devil, but that they have been endowed as super figures, omnipotent beings, biblical prophets, Jesus, or the nemesis of all that is good,
The Joker.

I say all of this at lunch and someone logically opines. "I think he just went postal. He'd been marginalized so many years, he had enough, wanted to punish the world." Postal, if you recall, is a reference to an actual postal worker who, fired from his job, returned and attacked his co-workers.

Could be. But most kids who show up at a university counseling center are not seen by the director who happens to have a research background in psychosis. They are seen by staff clinicians. We can all do anger management.

Then today we hear about the first copycat. He's a joker and has been fired from his job. He has an arsenal.
. . . a Maryland man who called himself "a joker" and had an arsenal of semiautomatic rifles threatened to shoot up the business in Palmer Park from which he was being fired, and was wearing a T-shirt reading, "Guns don't kill people. I do," when confronted by officers . .

The man, identified in a search warrant as Neil Prescott, 28 years old, made multiple threats in phone calls this week. The shooting in Colorado, coupled with the "joker" reference, gave the comments extra urgency, officials said.
The difference between Holmes and Prescott?

Holmes is a brilliant young man who graduated at the top of his class, then seems to have gradually declined following graduation from University of California. His mental health deteriorated to the degree that he failed his neuroscience exam in June and dropped out. It appears that his sense of identity merged with a movie character, a villain, the Joker. He did what the Joker is supposed to do, set out to slaughter his "enemies." He did so with precision, planning, deliberation, joy. The Batman movie is all about slaughtering enemies, the perversity of killing. Great stuff, must be.

Neil Prescott, on the other hand, has no problem with his identity. "Guns don't kill people, I do." Prescott knows who he is and what he is doing.
Neil Prescott (ABC news)

He is a man known for his sense of humor, who plays jokes, and who seems to be something of a neighborhood watch kind of guy.  A gentle giant.  He has a huge arms collection.

He is fired from his job. He makes several calls threatening revenge. But he doesn't carry out his plan. Calls for help, maybe? Or attention? Someone stop me, 
I want to kill these people who have ruined my life by firing me. 
Someone pay attention, here!

They both planned an attack, but only Holmes carried his through; the pain, or at least the depths of the illness, greater than that of his copycat.

therapydoc

Wednesday, July 25, 2012

Football and Culture

You all know that I love the Cubs, a team that tends to lose, and that I overcame a certain trauma by merely going to a Sox game.  Sports builds confidence when we play it-- when we play with good sportsmanship and camaraderie.  Or it should.

Someone told me the story of a new boy in my neighborhood.  He was outside playing catch with his brother.  A younger child watched from afar as the two played a fairly simple game.  The younger one seemed entranced, but shy.  He was different, special, and most of the neighbors knew this.  Affable, lovable, he was still excluded usually from play.

The new kids had a sense of this and didn't especially want to invite him to play.  But they did, and they took the time to teach him the rules, too, even though it slowed down the game, made the game somewhat less enjoyable, as sport.

As a human experience, we could say, the stature of play, the purpose of the game, because they include a peer rejected child, exploded.  The experience overall, for everyone's self-esteem, improved exponentially.

Historically, sports are exclusive.  It is all about the best players, the best teams, the best, the best, the best, and it is difficult, surely, to somehow not feel deserving and privileged, just being on a team, being a part of a winning team, especially, whether it is high school varsity sports, college ball, or professional athletics.

Culturally, too, sports have been tainted with racism and sexism, as ecosystems can be, it seems, until shaken down, forced to change.  In football it took a Jerry Sandusky to shake it down, to rattle the culture, scream out, change.

Sandusky, a man who systematically sexually assaulted, oh let's use the word, raped little boys under the watch of a most powerful institution, Penn State, funded by an even more powerful institution, the NCAA, and an icon, a virtual demi-god, Joe Paterno, a winning coach.

President of the NCAA, Mark Emmert, says it best:



The NCAA took away every win.  Mr. Paterno, who passed away weeks after exposure of the incidences, probably knew his ship had sailed. A transcript of the statement above, for the hearing impaired, reads as follows:

"No price the NCAA can levy will repair the grievous damage inflicted by Gerry Sandusky on his victims.  However we can make clear, that the culture, actions, and inactions that allowed them to be victimized will not be tolerated in collegiate athletics.

One of the greatest dangers stemming from sports is that the sports themselves have become too big to fail, indeed, too big to even try.  (This seems like a nod to the thinking that Penn State at the very least, Joe Paterno, knew what was going on).

In the Penn State case, the results were perverse and unconscionable.
Chairman of the NCAA Executive Committee, Ed Ray further comments that the authority to do this is there, and that it is morally incumbent.
 "...we also have the responsibility to say that such egregious behavior is not only against . . bylaws and the constitution, but also against our value system and basic human decency.  
Jerry Sandusky was convicted for more than 40 counts of sexual assault on children.

Sanctions:
A $60 million dollar fine, one year's revenue of a football team (there's a cover-up incentive if ever there was one).

A four year ban on bowl games, meaning if the team made it to the game, they wouldn't be able to profit from them.

Forty NCAA scholarships, gone.

Probation for five years, and an "academic integrity monitor"

This wipes away all Penn State wins under the coaching of Joe Paterno from 1998 to 2011.

Paterno will no longer be the top coach in football with the most wins. (13 years of football, gone with the swipe of a pen). Instead he will go down in infamy, the man who couldn't turn in his friend.

The story becomes even more amazing, if you think of it from an addict perspective, from the part of the enabler. We could call Paterno, and Sandusky's family, people who knew and said nothing, enablers. They enabled perverse, horrible crimes to continue. They couldn't stand up and say, "What in the world is happening?!! This has to stop, even if someone goes to jail, even if he is a provider, a spouse, a father."

The Sandusky family is taking umbrage at the NCAA sanctions, are offended that they weren't consulted first.  Rather than hide from publicity (you would think), they are open about being hurt at the lack of interest on the part of Penn State.

They issued a statement, a long document, saying that the sanctions weren't thought out, that they were issued without consulting the family. Just to be clear, most of the time, from my reading of hundreds of Law and Order cases, when crimes have been discovered, those who are associated with the crimes are under investigation, too, for complicity. They aren't consulted about the sentence.

This may seem bizarre, but is testimony to the depths of corruption, how little is understood by the average sports lover, perhaps the average American, about the egregiousness of child abuse, how damaging it is. Nine out of ten violent criminals in penitentiaries are the victims of childhood abuse, violent abuse. Sexual abusers, too, learn their methods, from sexual abusers (not that pedophilia hasn't some genetic components, that's not what this is about).

Ed Ray, Chairman of the Executive Committee of the NCAA says that not only does the NCAA have the right, but it has the responsibility.

Oh, what a movie this will make. Talk about culture.

therapydoc

Friday, July 20, 2012

James Egan Holmes

Does he look like The Joker?  Does he think he's Batman's nemesis?

What is wrong with this guy?


What we have is a shy kid, a boy who didn't engage when others tried to talk to him.  Or so says a San Diego neighbor, a young man who played on the same soccer team in high school.  He never socialized, never had friends.

What we know is that James Holmes is a brilliant young man.  A neuroscientist, at the top of his university class, an honors student.  Then, after graduation, no jobs.  He flipped burgers.

Graduate school, obviously, a PhD should be the next step.  Why wouldn't that be taken for granted?  Why McDonalds?  McDonalds?????  Something's not tasting right with that.

So he started school in Colorado, but he quit in June.  Quit?  Why would a nerd, clearly destined for academia, quit graduate school?

Tempting to think--psychopath.  Or Anti-social Personality Disorder, Social Phobia, Schizoid Personality Disorder.  Even people with Asperger's can't handle the social pressure of college.  It isn't the academics, not usually.  It's the socialization, the expectations.  We live in a social world.  But violence isn't associated with Asperger's.

And psychopathy is diagnosed during childhood.  James didn't even have a traffic ticket, let alone an altercation, a fist fight, a stolen candy bar.  This 24 year old man didn't pick pockets.

It is likely we'll hear that he suffered from Schizophrenia.  Or another psychosis, even Bi-Polar Disorder (see how not romantic that one really is).  Paranoid Schizophrenia affects reasoning, patients hear voices, believe that God talks to them, tells them to do things.  Some think they are Jesus Christ.  And some think. . . they are the Joker.

therapydoc

Monday, July 16, 2012

Banking on Anxiety and Depression

Riding my bike to work on a summer Sunday morning is joining a love-fest, literally, although we tend to use the word love rather loosely.  Like I love my new tablet, or I love my new crocks.  But if you get out of the house in Chicago before it gets hot, then you're among the the getter-outers, a community of people loving their morning, people who plan their exercise.

And I'm forever ragging at you to become a part of one kind of community or another.

There's a breeze, too, and the flashing sign at the community bank tells me it is a balmy 81 degrees, my favorite temperature.  People are saying Hi, and they are smiling, bikers showing off cool bicycles, walkers their sneakers, runners, their bods.

We're all out at the bike path by the Chicago River, really a tributary that winds through parkland and splits the city by east and by west.  Nobody's impressed by the Chicago River, but the ducks like it, and lush trees that line it seem happy.  We get an occasional coyote or deer for excitement.

There's a Little League game going on, and one team is sporting shirts sponsored by Johnny's Ice House. You would think Johnny's is a place to pick up block ice on the way out of town for a road trip, but the Ice House is an indoor hockey rink.

But back up to 6:30 a.m. when I started writing this post.  I had been up only an hour, thinking about Daniel Smith and how to pitch his new book, Monkey Mind.
A definite flavor of the month,
Daniel Smith's Monkey Mind,
candy for professional
and layman alike.

There’s this saying: Early to bed, early to rise.  
And it works, too, assuming anyone could do that, get to sleep early.  


Sure, we could get to bed at 10:30.  But fall asleep?  Too much stim pounding at our brains.  FaceBook, Scrabble, YouTube, last week's Burn Notice calling our names.  Sometimes we even talk to real people at night. We have tea, make a stab at making love.

Taking a shower and getting ready for bed then, isn't a simple matter.  And falling out, as we say, dozing off, not a given, not unless we somehow manage to live caffeine-free lives and deliberately struggle through the day without a nap.  Although a catnap, 5-10 minutes won't affect us at night.  Doctors are masters at these. 


To wind it all down before eleven, the dogma is that it's good to avoid eating dinner after 7:00 p.m., and forego, maybe, late night ice-cream.  We should lay down, not sit, but lay down that weighted-head so the reticular formation in the brain stem gets a nice blood flow, feels dizzy with oxygen.  Best to do this with a good book, something that we can unconsciously drop that won't break.  


And yet, our bio-rhythms still may not cooperate.  


Driving somewhere last week, listening to a sleep expert on NPR, the talk was about how to figure out how many hours of sleep we really need per night.  There's a way to find this out:  


Go on vacation.
Go to sleep when tired note the time.  
Don’t set an alarm, wake up on your own and again, note the time.  
Repeat for a few days.  


As the body gets used to the idea that there's no need to get up to do something, it settles into a nice groove, doses itself—no Ambien necessary—to the proper sleep recipe, lending the sleeper a productive next day.

Ah, but I ask.  What about those who don’t need to set an alarm, who naturally wake up with the rooster.  Our expert would say that this is our natural rhythm.  But we know that early morning awakening is a symptom of depression!  Not always.

There is surely a greater truth, and more to resetting the clock than the vacation method.  It has to do with what's going on in our heads, in our minds.  These won’t necessarily shut down under any circumstances, even when we know our cycle.  


The "cycle" is affected by emotion, by thought.  We obsess, we cry.  We deliberate, we count.  Our angst is palpable.  Our hearts beat audibly, our breathing is short and words, countless words, invade our consciousness, usually self-deprecating words.

Wait.  Isn’t that anxiety? 

Well yes, as a matter of fact, it is.  


All that just to introduce the book that put me to sleep at 12:35 a.m. last night, two more pages to go.  It's a memoir by a guy who suffered from anxiety for almost all of his conscious life, a Simon and Schuster that reads like really, really, intelligent chick-lit,  In other words, gold.  


And I have it for you, literally.  Nina, the good publicist, sent me not one, not two, but three copies of Monkey Mind.  I get to keep one, obviously, to let my anxious mother, brother, sister-in-law, and all of the people I know with anxiety, read it.  


The other two are give-aways for the blog!

I’m thinking that the contest begins next Monday, July 23, 2012 at 8:30 a.m. Chicago time, which is Zone 6, Central Standard Time.  The first two readers to email me get copies of MONKEY MIND.  Write to TherapyDocATgmail.com.  

You’ll be so happy you did.  Daniel Smith is a wonderful writer and you will recognize his story, the themes, the therapies.  You KNOW Daniel.  Maybe you ARE Daniel in another body.  I don’t know.  The story is so familiar and yet so unique, as is everyone's.  And you'll love the mother-father-son dynamics, naturally.   

Enough said.  I just can’t bring myself to spoil it, as I typically do with these things.



Other authors to make it to my bedside slush pile, because how else is a person supposed to sleep?  We talked a little about this one, ALMOST A PSYCHOPATH.  But I don't think I showed any pictures.
Ronald Schouten, MD, JD

James Silver, JD
Here are the guys who wrote it.  They do have a bit of that Law and Order aura, don't they?  For those of you who are considering forensic psych, James Silver and Ronald Schouten are a very good place to start.

For the rest of us,
Almost a Psychopath: Do I or Does Someone I Know) Have a Problem with Manipulation and Lack of Empathy? is better bedside reading than the DSM IV-TR for differentiating between people who merely enjoy playing with us (mischief) and those who can't help themselves, simply have to engage in criminal behavior.

Clear, informative. These professors are among a handful writing for the Almost series at Harvard (publisher, Hazelton), featuring the almost syndromes.  Some of us have clusters of features of different disorders but not enough bullet points to qualify for the big prize, a diagnosis.  We can't brag, technically, "I AM a psychopath," for example, but we can say we're awfully close.

It is difficult to host a disorder, especially the Axis I disorders like the mood disorders, anxiety, substance abuse, and anorexia.  It is an entirely different problem being the host, and infecting/affecting others.  By definition, some disorders do this, make everyone else miserable, too, not just the host-- especially the Axis II or personality disorders.  That's why it is good to read up on them.

If you're a therapist and you read Almost a Psychopath you'll find your gangbangers, the ones who want to change, and the reformed drug addicts and alcoholics who used to knock down old ladies for their purses.  You'll find the people you treat, and you will surely see them with a new set of eyes.  Of course if you are a relationship therapist, you might pat yourself on the back and say, Hey!  We already do that!  We're up to speed on the therapy!  And what a feeling that can be.

John Coates, The Hour Between Dog and Wolf

The fellow on our left couldn't handle success, couldn't be satisfied as a successful economist and hotshot trader.  He had to become a neuroscientist.  Those overachievers, seriously.

The book, The Hour Between Dog and Wolf is an everything-you-ever-wanted-to-know about the arousal systems in our bodies.  We're triggered (I know, shocking) and we behave.  Our senses, ourselves.  But if you haven't taken enough biology or psychology courses, and you want a taste of this and a good story, how real traders behave on real trading floors, why, then this one's for you.

And here I thought it was all about gambling, but a little more calculated,with a little more thought.  And it is about gambling and risk, the moment, if not the hour, of supreme clarity that motivates the trader to make the trade, to make millions in a moment.  Or lose them.  Who wouldn't want to read about this?

Because I'm not a medical doctor and because Professor Coates clamors on quite a bit about testosterone, I asked my in-house medical expert to read a few chapters to give me his spin.  FD relates the following:

Coates is saying that as the market becomes volatile, hormones (of stocks and commodities traders) are released, among them testosterone.  Coates feels that is is testosterone that drives the bigger risks. Could be a good thing, but could be bad that this is the case, but guys, especially, have to be in touch with their bodies, occasionally reel in their drives.  We've been saying this all along, you know.

The problem with the theory, according to FD, a theory presented as truth, is that testosterone is a slow acting hormone that isn’t released in sudden surges and it doesn’t yield immediate effects. 

People take testosterone for bone mass and muscle growth, and they have to take it long term regularly for months for effect. 

So what is it that turns the dog into a wolf?  We want to know!

Culture, more than anything else, FD is thinking, and adrenaline.  


Our hormonal systems are given plenty of print in the The Hour Between Dog and Wolf, a nice Xmas gift fo the stock broker in the family.  It even gives time, if not equal time, to the women on the floor.  Theoretically, they should be less successful, no, more successful.  Wait until the people at NOW get their hands on the book.


  
  
Bill Knaus, Ed.D, the mind behind
 The Cognitive Behavioral Workbook for Depression, 2nd ed.



Depression: The Guide for the Newly Diagnosed is a short little book, the type you need for your office waiting room.  It always amazes me how people who might have suffered from depression for years, truly don't understand the disorder.  All the more so, the newbies to the dark cloud.  Lee H. Coleman's little paperback can change all of that.

I think we’ve already given Bill Knaus a shout-out, The Cognitive Behavioral Workbook for Depression, 2nd ed.  Bill’s an edpsych doc, so of course he wants to educate.  And like most mortals, he has suffered from depression. A patient who read it berated me for not mentioning this fact to her.  Without knowing that Bill has suffered, why would she read him?  How could he relate?

Fine, so now you know.  


Excuse me.  The pool is about to open.  I gotta go change.


therapydoc

Thursday, July 12, 2012

Things Run in Threes

Three quick stories, the types of things that roll around in this therapist's head during the course of a day.

Jesse Jackson Jr.
The Legend, the Dad, Jesse Jackson Sr.
 (1) Jesse Jackson Jr's Mood Disorder  


Our biggest local news is that Illinois Congressman Jesse Jackson, Jr., son of the legendary political figure and civil rights leader, Jesse Jackson, Sr., is in Arizona receiving intensive medical treatment in a residential facility.  Rumors are flying that the congressman is there for alcohol or drug addiction, but the official word is much less exciting.  He's suffering from a mood disorder.

It was really annoying yesterday, if you listened to the news on radio.  Every third sentence had to be about this story.  Forget privacy, forget respect.  He's suffering from depression, and he can't work and why can't it be left at that? This shouldn't be the most catastrophic or interesting story of the day!  Hasn't some terrorist been stopped mid-air in China?

Then today it comes up in therapy not once, but twice, patient's versions of:  I knew, he had it!  I could just tell.  One week gaunt, the next week perky.  Then listless, then . . .nothing about Jesse in the news for months!  And now, THIS! 

And I realized that it is a good thing.   It is a good thing that psychiatric illness is normalized on the news, that we can talk about it, that people recognize depression, especially, as a fairly common illness, not something that can be helped if only we (a) just worked out! (b) ate right, (c) married into the right family, etc., etc.  It happens to everyone, depression, which is what these broadcasts recognize.  Or more importantly, to me, a cutting edge population, the clinical population, feels less alone.  They are the people in the know, and they are telling us, what's what.  Delicious.

(2)  Adult Asperger's and Depression

This one explains so much!
Years ago I had a patient with Adult Asperger's, and have seen many since then.  Once you know what to look for, it isn't hard to pick it up.  Not that this is a common diagnosis, but 1 in 250 isn't exactly one in a million. Ever since Baron-Cohen came out with a better test for Adult Asperger's, more and more people with this compelling disorder are coming to therapy.

Tony Atwood
I found a list of affirmations in Tony Atwood's book, The Complete Guide to Asperger's Syndrome,  and brought it to work with me one day.  The patient read through it and told me that it didn't matter. The depression people like him have (depression is often associated with Asperger's) is born of deficiencies that might improve, but will never be overcome (we shall overcome): misunderstanding social norms, not knowing the intentions of others, cluelessness about people's expectations, a sense of isolation ingrained over a lifetime.  No amount of affirmation, I deserve respect for being different! can change this.

And yet, like other AAA patients, his sense of humor has me on the floor.

He shows me a link to a tee shirt he found online that says,  I'm not rude. . .I have Asperger's, and he tells me he could never wear it.  Too embarrassing.  We talk at length about his sense of despair, his inability to hit the mark, socially. his inability to put words on feelings his whole life. He hasn't got feelings so much as rationale.  His rationale, and only his, since empathy he tells me, for someone like him, is like Greek to a Jew.

(3) The Runaway Train of Depression

We talk a lot about how depression can feel like a runaway train.  Women in particular can't stop the crying, especially if they are suffering before menses, PMS.  It's like, sure, we're depressed.  But our bodies have to cope with our hormones, too?  Or is it all, hormonal.  Feels like that, sometimes.

It doesn't matter, really.  What matters is the feeling that this is unstoppable, that the tears will never dry, a feeling of loss of control, a feeling of serious crazy.  Insanity. What is crazy if not lack of control?  Nothing.  A person feels as close to insane with these feelings.  It is not unlike the insanity people with Asperger's feel, like they are aliens, can't speak this unintelligible language, the language of social cues.

Segue to Asperger's just a moment, because it can be so depressing (my last referral had no idea he had the diagnosis, came in with suicidal ideation).  Why do they want to be together in groups! What's with these get-togethers?  Ridiculous.  This is how it feels to have Asperger's, and this is how it feels under depression.)

Even imitating the natives, it is hard to be one of them-- both conditions.  But merely having Asperger's, being unable to read what is expected, not knowing what anyone wants from you if it is not spelled out, a person does feel out of control, a mistake will happen at any moment in a social situation.

And it does.  Insanity, not unlike the insanity we feel when we can't "manage" our emotions, especially sadness.  We're supposed to be able to do that, right?  Manage them!  And guess what?  Sometimes, that's impossible.

So what is the cure for this craziness?  For both crazinesses.  For the runaway train, those tears that don't stop?  People who are in a relationship can, and often do, ask a partner to hold them.  Holding therapy is nothing new.  We use it for kids all the time.  Kid has a tantrum?  Hold him.  Kid is sad?  Hold him.  And let the child determine when it is time to let go.

Same for a woman, or a man, weeping, thinking depression is insanity, off the charts, unstoppable.  If she can get someone to hold her, if he can get someone to hold him, it helps.

There's usually a problem with that, however, which is that sometimes the trigger for the tears is something that this partner said, or something not done.  So asking for a hug puts a vulnerable individual in a position of potential rejection.  They just argued.  Timing is bad.

This is where I say, Own the craziness.  Just like with Asperger's.  Own that you feel out of touch, insane, that you are in a crazy place and it is nobody's fault, least of all that partner's.  Even if it is, you don't say that, not if you want to neutralize the fight and start over, get the drug, the feeling of human arms around you.

That's the cure.  It really is.  One of them, at least.

therapydoc

Wednesday, July 04, 2012

It's a Free Country

In America, the Fourth of July is a celebration of self-rule. The first settlers (now a bad word, settlers) suffered under taxation and fought a war to break free of British rule.  They won.



Whitney Houston (sniff, sniff).

So we shoot rockets into the sky and sing our national anthem.  Some of us walk around all day singing God Bless America,  The Battle Hymn of the Republic,  America the Beautiful,  and My Country ‘Tis of Thee.   I love them all, American classics.

The skies light up at night, throughout the week, even in cities where private ownership of explosives is  illegal.  I could see four separate fireworks displays from my balcony last night.  All to celebrate independence, theoretically, something therapists discuss every day.

NPR, to keep it in perspective, has a nice discussion of what July 4th really means.  We should think about freedom as the freedom to walk the streets, heads up something not everyone has.  Some of us are in real prisons, penitentiaries.  Other prisons are virtual; they're in our heads.  Some of us are prisoners in our own homes, at the mercy of whims of dominant partners, parents, guardians, institutional staff, and care-givers.

So here's another short spin on it, because we all have to get to the pool or the beach, begin the potato salad.

Volunteered slavery, doing what the doctor, parents, or other authority figures tells us to do, feels like the opposite of independence.  Since it is our choice, follow orders or not, we'll often procrastinate, or deliberately act out, not follow at all.  This deludes us into thinking we’re in charge, independent.

Nobody is the boss of me. I can do what I want, when I want. Whatever it is can wait. It's a free country, America.

The paradox is that if we don’t want to do what's good for us, we'll find a reason not to do it, and of course, nobody is forcing us to do anything.  We can lie in bed as long as we wish in the morning. Our parents might throw a glass of water in our faces, our spouses or partners may flip off the covers.  But we can decline to cooperate, nevertheless.

True psychological independence is separating out the pleasure of what we want to do, which is slack off, from the pleasure of doing what is good for us. The pleasure of saying No! You can’t make me! versus Oh, that sounds like a good idea, actually.  I should, I will.

No, can be a stubborn pleasure, won't necessarily please us in the end or make us better people, not stronger physically, nor psychologically.

Saying I’ll pass on the pie, but save me a piece is good for us (how we hate those people).  That kind of control is a source.  Every anorexic knows this, which is why it's good to qualify control.  In fact, in therapy we're not all that big on control, a famous line from the movie Ordinary People. But self-control feels good, feels like independence, assuming we're not doing it to spite anyone.  If we are, psychological dependence factors in.

Getting change to be a choice is beyond difficult.  Convincing others that they are hurting themselves, not doing what is in their best interest, impossible.  It is what therapists work at so much of the time, but ever so subtly. Really?  Please build on that.  I’m so interested. That’s working for you, is it?

Very mild spoiler:

Saw The Amazing Spider-Man last night. I won't give away any plot, suffice it to say that the new Peter Parker, Andrew Garfield, is handsome and engaging, as is the entire cast, especially girlfriend Gwen, played by Emma Stone.  The writing is good, too.

In this film Peter (Spider-Man) is put in the position of rebelling, seemingly, but he doesn't want to  rebel, he just can’t help it.  He's always coming home late, making Auntie May and Uncle Ben worry. They try their best to tell him that it isn’t cool, making them worry like this, and not necessary.  Peter has a cell phone.  You could call, you know.

At one point Uncle Ben lectures Peter via voicemail.  Peter starts to listen then turns the message off.  Most kids do this, right? They don’t listen to our lectures, aren’t interested. To really listen, a person has to elect to listen. If you have had the privilege of going to college, you know that the good lectures at school are in classes called electives.   We choose to take electives, as opposed to those other classes that we have to take, requirements. Electives get our rapt attention.

Thus it is electing to choose what is healthy, what is good for us, that turns volunteered slavery into independence, more so in life than in the movies.  Only then, when we choose, does it feel we’re in charge, in control. And control feels like real freedom because it is not submission. Control is often about having the feeling of independence, if not the reality. Again, think anorexia or any eating disorder in which we choose to eat-- or not to eat.

Happy July Fourth, Happy Independence Day.  Don't drink and drive.

Not that we're telling anyone what to do.

therapydoc


A couple more patriotic songs before we go:

Celine Dion, God Bless America

And Marian Anderson, 1939, at Lincoln Memorial, after being denied the right to sing at Constitution Hall by the DAR, Daughters of the American Revolution.

Sunday, July 01, 2012

Summertime Snapshots

1.  CAD, better known as Cub Affective Disorder
Anthony Rizzo

It has never been easy, being a Cub fan.

If you don't follow baseball, then you might not know that the Chicago Cubs always lose.  They always finish either last of second to last.  It is their legacy, with few exceptions.

Lucky for those of us who live in Chicago, there is another major league team, the White Sox, and they generally win.  So nobody really has to be a Cubs fan if they don't want to be. They can don black and white, as opposed to blue and red, and call themselves Sox fans.

But if you live on the north side of the city then you are supposed to be a Cubs fan because the Cubs play on the north side at Wrigley Field, whereas the Sox play on the south side, now US Cellular, formerly, Comiskey Field.

Comiskey Field before it became US Cellular

 Indeed, some people don't know this, that when you move to the city, depending upon your address, you sign up to support either the Cubs or the Sox.  Some spend the rest of their lives regretting their error.

Every year, we Cub fans are offered hope, either in the form of a new owner, or a new manager, perhaps a trade.  This year's tease is Anthony Rizzo, the new first baseman who hit a home run on Saturday to win the game for the Cubs.  He won another one for us today.

And here we are, suddenly yanked around like yoyos, and all it takes is a homer, albeit the first, off the bat of an Anthony Rizzo.  All of sudden, out of nowhere. . .hope.

The joke is that some of us were just about about to coin a new disorder, CAD, thanks to a patient who made it quite clear that it made sense.

CAD, Cub Affective Disorder would be like SAD, Seasonal Affective Disorder, that winter blues diagnosis of choice for those who live in colder climes.  Except that those likely to suffer from CAD would be Cub fans in the summer.  Sadly, because Chicago is a city of the north, Chicagoans are vulnerable to both.  We can be a sorry lot.

Whether or not we'll suffer from CAD is yet to be determined, of course.  Things do change for the better.  There is certainly room, and we still have time.

One thing for sure.  Cub Affective Disorder is a seasonal thing; it has a beginning and an end.  We'll get over it, although some of us recommend acceptance, and low expectations, to soften the blow.

2.  Termination Issues

It is so easy to make jokes at the expense of clown fish.  Kids in therapy laugh as soon as they see them.  They ask, What are their names,  Nemo 1 and Nemo 2?

Uh, duh.

No, not terribly funny, you're right.

Another joke:  What's up with the fish?  How are they doing today? 

Oh, they're just clowning around.  You know.


The fact is, that being an aquarist in a small office means that your fish get a lot of attention.  And when you suddenly remove them, leave an empty tank, patients get really upset.

Where are the clowns?
Send in the clowns!

You tell them that you found them a better home.  Your son has a reef tank with an anemone, the clown's natural lover, and his reef looked lonely with no fish.  His own jumped ship while he was at work toiling away until late into the night; his feelings, loss, guilt, sadness, sheer horror, something he can't even talk about.

So this solution worked for everyone.

Everyone, that is, except for people who had no idea this was in the works, who never had a chance to say goodbye to the clowns.  Termination, you know, is huge in therapy.  We take it very seriously.  When we go on vacation, everyone knows months ahead of time.  If we're leaving town, six months, minimum, notice.  Nobody, no patient, nor fish, nor therapist, simply doesn't show up in therapy one day.

I'm sorry.

3. CBT and the Pool

I have a swimming pool in my building.  An outdoor, heated swimming pool.  Not that I love to swim.  At my age, swimming means something has to hurt, in my case, the elbow, a tennis injury almost ten years old, one that hadn't hurt for about a year, until now.  But I'm not complaining.  Getting out to do laps with FD early in the morning has proven to very beneficial, a high you could say.

But here's the thing.  Every morning I go through the same routine.  Do I want to do this?  Do I have to do this?  Maybe I shouldn't do this!  Why do this?  The water might be cold, and as a cold averse individual, why would I volunteer to dive into cold water?

On the other hand, it might be cold.  But it might be warm.  Peggy, my new best friend who swims every day, probably more than once a day, tells me that it only feels cold because the air is warm.  When the air is cold, the water feels warm.   When the air is warm, the water feels cold.  Makes sense.  So swimming when it's cooler feels sublime.

No matter, not the point.  The point is that I have to consider this, that it will feel cold sometimes.

The trade-off is that even if it does feel cold, it won't for very long, as the warm-up is only a minute, and the benefits, the physical and psychological benefits of the swim are worth it.

Thus the rational answer to the dilemma is, Swim, you bum.  Just swim.

So I approach the elevator early in the morning wearing a sweatshirt and carrying a terry-cloth cover-up and towel, a change of clothes, resigned to whatever will be.  In my head there is no feeling of depression at this moment, no matter what might have bothered me the day before.  Resigned to swimming, it is as if I can predict that the day will go well, start well, at any rate, a certain sense of accomplishment, confidence, the Neo syndrome, will take over.  The Neo syndrome is something someone keeps trying to explain to me.  Neo is a super person straight out of the movie The Matrix.  I tried to watch this movie but when Neo started to turn into an ugly creature, I had to turn it off.

All this to tell you that there is a book that New Harbinger Publications sent to me that is totally worth buying (and I rarely, if ever say this, worth buying).  For the price of a co-pay, maybe a few pennies more, you not only get a workbook that is well-written, infused with poetry and contemporary thinking (Depression is beatable!  We can do it!), but the author also values metaphor, teaches the reader how to think metaphorically.  And best of all, he's a naturalist.  He's the closest thing we have  in psychiatry to Thoreau.  He'll put you on Walden pond and you will like it, or we'll throw you out of Eden (yes, yes, we're mixing metaphors, sue me).  Get away from the grind, think out of the box, and most of all, get off your ___.

Theoretically all of cognitive behavioral therapy is this way, encourages thinking and behaving in ways that are different, better.  But frankly, it is a much easier thing to talk it, than walk it.  Your therapist can yell at you, Just take a walk every day or don't come back!  And you might never come back.

Bill Knaus (William J. Knaus), however, makes it easy.  He illustrates how to push off, quit procrastinating, take each step, one at a time, just as we do in therapy, week after week, in that fight against a most difficult, but treatable disorder, depression.  Not surprisingly, one of the first directives in the Cognitive Behavioral Workbook for Depression is exactly the one nobody likes hearing, "JUST DO IT."

So yeah, I'll be sad, after Labor Day, when they close the pool.

therapydoc